Evidence-Based Care and High Reliability: A Potent Combination

In order to realize the full benefits of evidence-based practice, health care providers must take the necessary steps to bridge the implementation gap between knowledge and action, and deliver effective interventions with high reliability.

Evidence-Based Care

Evidence-based practice is an approach to clinical decision making, which integrates:

  1. Best available evidence derived from systematic research;
  2. Expertise of the decision maker; and
  3. Expectations and circumstances of patients.

Numerous clinical interventions are backed by scientific research; here are merely three examples:

  • Beta-blockers, given to persons presenting with a heart attack, reduce the risk of death by 13% in the first week of treatment and by 23% over the long term.
  • In type 2 (non-insulin dependent) diabetes, a targeted, intensified, multifactorial intervention reduces the incidence of cardiovascular disease by 53%, nephropathy (disease of the kidney) by 61%, retinopathy (eye) by 58% and autonomic neuropathy (nervous system) by 63%, compared to standard care.
  • Annual fecal occult blood tests could prevent 9,600 deaths due to colorectal cancer in the USA annually.

Reliability in Healthcare

Unfortunately, despite the evidence demonstrating the effectiveness of these interventions, studies conducted in the USA have shown that actual compliance with evidence-based care is well below what it should be. In a study evaluating performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care, McGlynn et al. found that only 55% of the recommended care was delivered, i.e. 55% reliability.1 Based on our experience and systematic (albeit limited) observation, we suspect the compliance with evidence-based processes of care in Southeast Asian hospitals is no better (or worse) than the US estimates.

Consider the implications of 55% reliability: What if your car started upon turning the ignition key only about half of the time? You’d probably want to get the problem fixed straight away!

Is high reliability possible and achievable? Most certainly.

High reliability organizations (HROs), such as those in the nuclear power, chemical and aviation industries, typically achieve reliability rates somewhere in the order of 99.9999%! Like hospitals, these are complex systems where the reliability in performing tasks has many lives at stake. Unlike most hospitals, however, HROs have developed characteristics and patterns of behavior that lead to their exemplary level of reliability.

Evidence-Based Care + High Reliability = Desired Clinical Outcomes

Reliability principles can and should be applied to improve the consistency with which high-quality care is delivered, hence maximizing the potential benefits indicated by the evidence base. The individual patient has every right to expect 100% reliability in the processes that affect his care, especially those for which high-quality supporting evidence exists. He deserves no less.


  1. Gaede P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med [Internet] 2003;348(5):383–93. Available from: http://dx.doi.org/10.1056/NEJMoa021778

  2. Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001. JAMA [Internet] 2003;289(3):305–12. Available from: http://dx.doi.org/10.1001/jama.289.3.305

  3. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med [Internet] 2003;348(26):2635–45. Available from: http://dx.doi.org/10.1056/NEJMsa022615

  4. Nolan T, Resar R, Haraden C, Griffin FA, Gordon AB. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004.